Provider Demographics
NPI:1285101964
Name:DIAZ, ANNE MARIE
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CONNELL RD STE T
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1899
Mailing Address - Country:US
Mailing Address - Phone:229-244-4720
Mailing Address - Fax:
Practice Address - Street 1:410 CONNELL ROAD SUITE T
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3160
Practice Address - Country:US
Practice Address - Phone:229-244-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAG09180071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA059917025OtherDRIVERS LICENSE